Holly Tree Lodge Residential Home Derby

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Incidents and accidents were being recorded and analysed. However, these did not always evidence actions taken to minimise recurrence. For example, analysis of incidents did not identify a pattern of unwitnessed falls in the communal lounge. This meant the provider missed an opportunity to review staffing deployment to help prevent further incidents. Staff we spoke with knew how to report accidents and incidents and why this should be done. Staff told us if changes were needed to people’s care, this was shared through handovers and discussions.

The provider did not always share information with relevant external agencies. For example, the provider did not always inform CQC of reportable incidents.

We observed inappropriate storage of equipment in communal areas and raised this with management. However, this was observed again when we returned on the second day of inspection. This meant people did not consistently received best care, as learning from reflection was not embedded in practice.

Relatives reported that staff and the registered manager were responsive and acted promptly to address concerns relating to their family member’s safety and health.

The provider demonstrated a willingness to learn and improve including responding to concerns raised by the inspectors.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The digital care system could produce a hospital pack with key information about people’s health and care needs and how to support them. However, care plans lacked sufficient detail. For example, one person who required support with transfers did not have clear guidance on the type of sling to be used or the required mattress setting. This posed a risk during transfers and when people were admitted to hospital. Staff and external professionals may not have had access to essential information. This demonstrated the need to improve record-keeping to ensure information was accurate and up to date.

Prior to people moving into the service, a pre-admission assessment was carried out to ensure the service could meet people’s needs. People told us if they needed support from a health professional, this was arranged and documented. We saw evidence of appropriate escalation and referrals being made where required.

The provider assured us action would be taken to make the required improvements.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately.

We found insufficient scrutiny and oversight of safeguarding concerns and systems were not operated effectively. The provider did not maintain a clear record to monitor safeguarding referrals. Whilst we saw evidence of some safeguarding concerns being reported to the local authority, we were not always notified.

Staff we spoke with were able to recognise signs of abuse and understood how to report concerns. Staff had received training in safeguarding. Professionals told us people were kept safe.

People we spoke with felt safe living at the home. Relatives did not raise concerns about their family member’s safety. One relative told us when an incident occurred, the manager informed them a safeguarding referral had been made.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We reviewed whether the service was operating in line with MCA principles and how DoLS were managed. Where people lacked capacity to make specific decisions, applications for DoLS had been submitted as required. Where DoLS were authorised, we saw evidence any conditions cited in the authorisation were understood and met. However, the provider had not informed CQC when DoLS applications had been authorised, as required by law.

The provider had policies and procedures in place for safeguarding the people using the service. However, these were not up to date. This meant staff may not have followed current guidance, which placed people at risk of inconsistent safeguarding practice

The provider did not always work well with people to understand and manage risks. We found risks to people had not been assessed fully or consistently.

Risk assessments were not always in place for all identified needs. Where they were completed, guidance for staff was limited and not always reliable. For example, a choking risk assessment identified risk factors but did not contain information on food and fluid consistency, level of assistance, safe positioning, or how to respond if the person refused to wear their dentures. Care records and risk assessments were not consistently reviewed or updated. This meant staff may not have had clear or accurate information to manage risks safely.

We reviewed the records of 1 person at risk of developing pressure ulcers. There was limited guidance in place on how to manage the risk. The care plan did not clearly record existing wounds or skin concerns, although body maps indicated these were present. Repositioning records were incomplete. Although we were assured from speaking with staff the person had been repositioned and had not suffered harm, their records did not always demonstrate the care provided.

The provider worked with healthcare professionals to support delegated healthcare tasks (DHTs). DHTs are clinical tasks assigned by a regulated health professional to a trained care worker. Staff were trained and assessed as competent to administer insulin, and the activity was monitored by clinical staff. However, there was no policy or risk assessment to guide staff on what action to take if a trained staff member was not available to administer insulin. This placed people at risk if an incident occurred. We saw evidence this had been addressed before the assessment concluded.

People and their relatives were not always involved in the development of risk assessments

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the assessment, we found window restrictors on some upper floor windows were not compliant with safety regulations. There was no risk assessment to show this was sufficient to minimise the risk. We also found some radiators in bedrooms did not have covers.

We found some large furniture had not been secured to the wall and could be moved. This placed people at risk of injury if the furniture fell. In one bedroom, a window was damaged and not functional. There was no risk assessment in place to consider how this may affect people’s safety.

Moving and handling equipment was not always stored appropriately. For example, we found hoisting equipment stored in the communal lounge during our visits. Wheelchairs were stored in the dining area next to tables where people were eating. This posed a risk to people’s safety and did not promote a dignified environment.

We raised these concerns with the registered manager. Before the assessment concluded, we received written assurances that action had been taken to resolve some of the issues we discussed. The provider told us they would implement systems to monitor and manage the premises and equipment.

Health and safety checks were in place and up to date, showing the equipment had been checked, was compliant and in safe working order.

There was evidence required fire safety checks were completed and recorded. However, people Personal Emergency Evacuation Plans (PEEPS) did not always contain sufficient detail to support staff to evacuate people safely.

Some furnishings were worn and areas of the home required improvement. The provider was undergoing refurbishment, and we saw some areas had been recently redecorated.

People’s bedrooms were personalised. All the people we spoke with told us the home was well maintained, and repairs and redecoration appear to be ongoing.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

On the days of our visits, there were not enough staff deployed to meet people’s needs, particularly during mealtimes. There were staff absences on both days, and the registered manager and deputy manager had to support care delivery. This reduced management oversight of the service.

We observed people left unattended in communal areas. Inspectors had to seek staff support when people were mobilising without assistance. This placed people at risk of injury.

The provider used a dependency tool to assess staffing levels. This was not effective and did not reflect people’s individual needs. Although the manager sent us a revised tool, some needs had not been assessed correctly, and we could not be assured that staffing levels were based on accurate information.

Despite this, staff felt there were enough staff to meet people’s needs, and the induction and training prepared them for their role. A structured training schedule was in place and staff had access to relevant courses. We saw evidence of supervision, appraisals and competency checks being completed.

Relatives told us they felt there were enough staff and said staff were often seen in the communal areas.

Recruitment processes were not always robust. While applications forms were completed, interview notes were not always available to demonstrate the applicant’s knowledge and skills. In one recruitment file, we saw the Disclosure and Barring Service (DBS) check had been completed shortly after the person started employment, rather than before. The manager told us the person had not worked on the floor during this time.

Infection prevention and control (IPC) practices required improvement to ensure people were protected from the risk of infection. The provider did not always assess or manage the risk of infection.

We saw evidence that when people raised IPC concerns, action was taken to prevent occurrence, including cleaning schedules reinforced and monitored to ensure compliance across all days of the week. However, our observations showed monitoring was not always effective. We found areas of the premises were not always clean and well maintained. In one bedroom, we observed a soiled pull cord and a mattress requiring cleaning. We also found damaged blinds, and pressure cushions which required cleaning. We also found a non-foot-operated bin. This meant staff may not have been able to dispose of waste in a way that reduced the risk of cross-contamination. The home employed domestic staff to help with daily routine cleaning tasks across the home.

There were multiple IPC policies in place Some were undated and others were out of date. This meant staff did not always had access to accurate, up-to-date guidance to support good practice. We were unable to find evidence IPC risks were consistently assessed and addressed.

Relatives had no concerns about the hygiene and cleanliness. People we spoke with told us they felt bedrooms were clean and staff wore Personal Protective Equipment (PPE) when required. Records showed most staff had completed IPC training. We observed staff using PPE appropriately and there was sufficient stock available.

The kitchen where food was stored, prepared and cooked was clean and there was a cleaning schedule to ensure it remained in a satisfactory condition.

The provider assured us action would be taken to make the required improvements.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We found topical creams were not always stored safely or labelled with open dates. This meant the provider could not be assured they were being used within the correct timescales.

There were no protocols in place for ‘as required’ medicines (PRN). This meant staff did not have clear guidance on when to safely and appropriately administer these medicines.

Medicine administration records (MAR) showed regular administration of most medicines.

Staff did not always have the information required to identify, monitor or respond to potential medicines-related risks. Risk assessments for people prescribed high risk medicines were not always in place, for example for people who were administered insulin. Medicine care plans lacked sufficient details and did not always include information such as allergies, prescribed medicines, or potential side effects.

The manager carried out regular medicines audit. However, these audits had not picked up the areas of improvement that were identified during the assessment.

Medicines were disposed of safely and staff received training the safe management of medicines. Competency assessments were carried out to ensure staff were competent. We observed medicines being administered in a discreet and safe way.

By the end of the assessment, the management took action to rectify some of the concerns raised in relation to medicine management, including removing unlabelled creams, implementing PRN protocols, and completing relevant risks assessments.